12-Step Programs versus Evidence-Based Addiction Treatments

This post is part of a series of guest posts on GPS by the graduate students in my Psychopathology course. As part of their work for the course, each student had to demonstrate mastery of the skill of “Educating the Public about Mental Health.” To that end, each student has to prepare three 1,000ish word posts on a particular class of mental disorders, with one of those focusing on changes made from the DSM-IV to the DSM-5.

Alcoholics Anonymous groups are one of the oldest and most popular methods of rehabilitation for addiction problems. Since the 1930s, when AA was formed, a variety of addictions have stimulated the formulation of different types of anonymous groups (e.g., Narcotics Anonymous, Gamblers Anonymous). The same 12-step principles govern each group, without many adjustments since they were codified in the 1930s. The main tenets of 12-step programs involve abstinence (complete sobriety), surrender to a higher power, admittance of wrong, and a willingness to change. The importance of establishing a spiritual connection with a higher power is stressed throughout the 12-steps. Step number eleven posits that:

[We] sought through prayer and meditation to improve our conscious contact with God (as we understood Him), praying only for knowledge of His will for us and the power to carry that out.

And yes, the “H” in Him and His is really capitalized. There is reported leeway as to which higher power with which one wishes to connect (although how much this actually occurs is questionable). However, there is little to no room for individuals without any religious or spiritual conviction in these recovery groups.

Weekly meetings typically involve personal confessions of “faults and failures” (relapses), 12-step review, and discussion. Step number five states that “[we] admitted to God, to ourselves, and to another human being the exact nature of our wrongs.” Every member typically has a sponsor that provides moral support. Sponsors are members that have been involved in the program longer than their mentees. According to individuals having gone through the program, having a sponsor is the most beneficial aspects of AA. The main weakness of 12-step programs, from a therapeutic perspective, is the unavoidable religious overtones. While this could be beneficial for some, it could simultaneously prove to be a detriment to a non-religious person seeking support during recovery. These programs also seem to breed an environment of guilt and shame, viewing addiction as a character flaw rather than a physiological or psychological disorder and supporting a very “all or none” view of treatment outcomes (abstinence is the only possible good outcome). And perhaps the most damning flaw of these programs is that they do not seem to work based on all available data.

But what’s the alternative? How about some methods to treatment that are actually based in evidence and reason?

For example, Marlatt’s model of relapse prevention promotes a more healthy view of addiction and facilitates client autonomy by providing psychoeducation on the recovery process. This model purports that client coping strategies and confidence, outcome-expectancies, and the initial substance effects determine response to high risk situations when relapse is probable. The abstinence violation effect is the client’s propensity to feel shame and guilt resulting from a relapse, regardless of it severity. A relapse typically increases the probability of a more severe relapse and a lack of confidence to continue with treatment. To prevent this from turning into a downward spiral of relapse, clients are taught understand abstinence as more of a learning curve; and thus, to expect relapse to occur, but less often with time. If relapse is expected it will not be considered a total failure, so then motivation to continue will be easier to find. Additionally, according to this model of relapse prevention, environmental factors are greater predictors of relapse, as opposed to personal will-power (which can also translate to personal flaws for some individuals).

Cognitive-behavioral therapy (CBT) is another therapeutic approach for treating substance abuse. CBT largely disregards the genetic/biological origins of addictive behavior, but rather assumes that behavior is learned through processes such as classical and operant conditioning, for example. The physiological aspects are perceived as the static platform on which environmental factors build, leading to individualized approaches to learning behaviors. An example of classical conditioning and the development of alcoholism might involve the following. Ted, a young twenty-something recently broke up with his girlfriend. The following day, Ted decides to stop by the bar after work to have a few drinks. A few drinks in (alcohol = conditioned stimulus; CS), Ted becomes fast friends with the bartender and a couple regulars sitting next to him (warm fuzzy feelings of friendship = unconditioned stimulus; US). Ted began to make this a common occurrence and soon became a regular himself (conditioned response; CR). Within few years, drinking became a problem for him. While social interaction, such as that experienced at the bar, may have by itself elicited those warm fuzzy feelings of friendship, Ted associates those feelings (originally the US changed to the CS) with the alcohol.

Because learning is believed to be the basis for behavior and thought-patterns, teaching new patterns of behavior (and thinking) is basis for the CBT approach (i.e., re-learning or un-learning). Some CB theories promote changing client environment, while others promote changing client reactions to the environment. Regardless of these small differences, the focus remains on the individual-environment interaction as the basis of CB theory and treatment. Another fundamental aspect involves the assumption that internal functions (thoughts and beliefs) impact external behaviors and vice versa. Thus, changing the patterns of one influences the other. Therapeutic alliance, often composed of motivational interviewing (see below) and contingency management, are also complementary to the cognitive and behavioral restructuring components of this approach.

Motivational Interviewing (MI) involves Socratic exploration which allows the individual to explore some of their own destructive and impairing patterns. Consistent reinforcement of client behavior, particularly with treatment of substance abuse, promotes awareness and monitoring of behavior. The mechanisms of knowledge, motivation, and resistance recognition are used to facilitate change. Formulaically, the assumption is that knowledge multiplied by motivation, divided by resistance will result in variable levels of change. The theoretical basis of MI lies within aspects of humanistic psychology, cognitive-dissonance theory, and self-perception theory. Instead of providing direct advice to the client, therapists employ “motivational” questioning or suggestions that allow the client to explore their own attitudes towards changing as well as perceived resistance to change. Clients are encouraged to engage in “change talk” (positive speech/thoughts about change) and avoid “sustain talk” (speech/thoughts about maintaining unhealthy cognitive and behavioral patterns). Change talk is based upon self-perception theory, which purports that people develop attitudes about their own behavior similar to interpretation of others’ behavior – by observing behaviors and then attributing attitudes that motivated them. Thus, change-related speech will contribute to change in behavior. This also builds upon cognitive-dissonance theory, in that people often feel ambivalent about changing their cognitive or behavioral patterns, even when they are self-destructive, like substance abuse. An increasing amount of literature has emerged over the last decade examining the therapeutic effects of MI. Meta-analyses indicate that MI is frequently equally as effective as other evidence-based treatments (e.g., CBT) for treating substance use problems.

Understanding the complexity of a client’s individual environment and thinking patterns is reflected in the emphasis placed upon the rigorous assessment involved in CBT and MI. For example, clients choose to seek treatment at different stages in the development of their presenting problems. Identifying client’s stage of change has been shown to be an effective technique for tailoring treatment to individual needs. Norcross and colleagues identified five stages: precontemplation, contemplation, preparation, action, and maintenance. Assessing the stage of change of an individual is particularly beneficial for clients struggling with substance and abuse problems. Stage of change can predict the outcome and effectiveness of treatment, as it reveals client’s readiness to rehabilitate. This, it turns out, is a regular part of CBT and MI, but not in the 12-step programs.

In sum, there are treatments that work for those struggling with maladaptive substance use. These treatments, though, are not what most people tend to think of when they hear the words “addiction treatment.” Hopefully, as the healthcare system of the United States moves increasingly towards requiring evidence-bases for what we do, this will change.

This article really makes sense to me. My six years in AA was plagued with the disconnect caused by the shame-talk and god talk, but man, it offers such community, so many friendships. Until one has to admit that she doesn’t buy it. Bye bye, then, with dire predictions from all of ’em. Alas, I know of no other community around here, anyway (Spokane, WA), that can compare, in terms of ease of access, welcoming outreach, eager hospitality. If only it weren’t such bullshit.
I’ve been a counselor to people with disabilities trying to improve their employment situations, and in that work I did use motivational interviewing, but only called it that when the organization started training us all in it. I think it’s the natural way friends help each other improve themselves. There need be no b.s. in it at all.

Another AA refugee here, like Barbara. She’s spot on about what works and what doesn’t. It’s also true that once you start questioning it you are out, there is no tolerance for dissent.

I was sober about 3 years and had successfully stuffed my atheism down. But I had my doubts about AA after seeing so few people get sober and stay sober for a meaningful period of time, and I was convinced there was something very wrong. I was at the bookstore in the self-help section and saw a book. Heavy Drinking: The Myth of Alcoholism as a Disease by Herb Finagrette, as UCLA medical researcher who had dedicated his life to research on addiction, and specifically alcoholism. He wrote the book because he was so frustrated by how the recovery INDUSTRY rejected the clear science he and his peer had developed. This was back in 1988 – the fact that AA is hokum is nothing new.

I won’t reprise it in depth here, but here are a few of the high points.

1. Alcoholism meets none of the criteria for being a disease.

2. Alcoholics always show the ability to modify and control their drinking under controlled behavioral experiments. There is no overwhelming compulsion to drink that one cannot control.

3. AA had no better a record of getting and keeping sober than people who tried to do so on their own.

4. The entire recovery industry is mostly run by people who’ve “recovered” in AA and they perpetuate the mythology. They profit greatly from it, running rehabs and counseling etc. Funnily, almost every rehab back then did a “tough love” kind of orientation where they told you up front that maybe 1 in 30 was going to get and stay sober for the long term – imagine a dialysis “treatment center” announced that to upon admission – you would run for the hills.

The medical establishment enables the con by going on along with the disease concept. This allows insurance and govt to pay for treatment and the entire system is perpetuated by the interests of those involved. Docs do this in part because they throw their hands up with alcoholics – they can’t help them, so they figure, AA can’t hurt.

The thing that is true is that if you use some of the simple tools they recommend – mostly not in the “Big Book” btw – you can get some time away from the habit of drinking. Taking it a day at a time or a moment at a time, putting it off for just 10 minutes, calling another alcoholic instead of drinking and congratulating yourself for even a day of sobriety – these all help. The program of steps itself is a copy of the Washingtonian 6 Step Program for spiritual development, and expressly Christian idea.

I left after 5 years because I simply could no longer participate in the fraud. 18 yrs later and I haven’t had a drink and don’t miss it. I finally found out “why” I drank, but that is for another post.

Thanks for the great contribution, Glenn. I’ll be having a series of posts up in the next month or so about AA and it’s origins, which I hope people will find interesting as well.

Neil Amitay

I am a happy member of AA who does not believe in god. My sponsor who has been sober for 23 years also does not believe in god. I do love the social aspect of AA for sure. It is important to me to be around so many loving (generally speaking) people who really do want what’s best for me.
I was in and out of the rooms for years and no one ever judged me (if there were any they kept it to themselves.) When I was ready to make a serious go of it I got lots of support from some group members, people who always treated me with kindness and respect and befriended me despite my using. These people are great friends to have and I would not have met them but for the rooms.

For those that believe in some sort of a higher power good for them. But it’s not for me. I do believe in a power greater then myself however. But this power is “earth based”. The power of many people working towards a common goal on a daily basis. Using those people who I call friends as a sounding board when I am not sure what direction to take with certain situations. Talking about stuff in meeting and often hearing people going through the same stuff or having the same feelings as I have and how they deal with it. Hearing other peoples perspective on life in general.
I feel free to talk about how I don’t believe in a higher power or god and no one has ever called me on it. I usually substitute the word “god” with “life”. I don’t believe in god but I do believe in life! I have found that working the steps has helped, I do actually comprehend the word serenity. I don’t believe god is doing for me what I can’t do for myself but I do believe that the support of people and some of the readings and my sponsor help me to do some of the things that I have never been able to do on my own. All of my friends outside of AA and my family as well are pleasantly surprised at how much calmer and more grounded I am.

I will finish with this (yeah quite the rant I know :-p. Check out the Alternative 12 steps that are not all “god this god that” I really love them. Also there is an paragraph from Bill Wilson in there about the 12 steps that I think every big book thumper should read before making any judgements about people who don’t go the god based route. Peace.

I can absolutely see how addiction can be a conditioned response. Cognitive behavioral therapy has been proven to work time and time again. Hopefully there are at least rehab centers that provide these types of therapies, if one can’t find them in outpatient programs.

As a Psychologist who is 5 years sober, I tried everything including psychotherapy, CBT, MI and nothing worked for me until I got to AA. The comment that “These (12-step) programs also seem to breed an environment of guilt and shame, viewing addiction as a character flaw rather than a physiological or psychological disorder” is misinformed.
In the rooms of AA I felt for the first time that I no longer had shame over my disease, as before, all of my willpower alone was not enough to stop drinking. Despite trying my best to change my thoughts, I couldn’t NOT drink. Also, in AA, openness about our character defects, such as self-pity (a big one for me) is done without shaming or guilt. I look around the room in a meeting when I share, and see other people nodding their heads because they know exactly what I’m talking about. Which is not shaming, it’s supportive. So if you have been informed that AA is a place where guilt and shame is encouraged, then I would encourage you to go do some further research and talk to more people who have been sober in the program for a period of time.
AA is not for everyone, but it is the LEAST shameful place I have found in my life. It is a place where I finally felt I could be me without being judged. Also, current evidence supports 12 step programs as being at least as effective as CBT and MI, if not more effective. Refer to research done by Keith Humphreys, Prof Psychiatry at Stanford University Medical Centre.
I find in my clinical practice I use only CBT and MI with certain clients, and others benefit from 12 step recovery. It’s not one size fits all. I just hope that allied health professionals get the facts straight on 12 step programs. They really do work, particularly when nothing else (i.e. CBT and MI) has worked. Shame and guilt has no place in 12 step recovery programs. It’s about Honesty, Openness and Willingness to look at oneself and what causes one to use or drink, without self shaming.
Good luck in your career and I hope this helps.

PJ

I’m a counseling student trained in MI and have participated as a parent advisor for a large nonprofit organization dedicated to helping families lead drug free lives, for several years. I am, also, the proud parent of an incredibly courageous son in long term recovery.

It was not until we stopped utilizing traditional 12 step-based philosophy and resources, as a means of support -both AA and Al Anon- that our son began
to demonstrate clear momentum in sustainable recovery. I’m not saying that our
son/our family gained ‘no’ benefit from being involved in 12-step based
supports. But, over time, we recognized inherent problems associated with what
we were negative, recovery-stalling influences in terms of the approach to recovery. In addition, and most critical, our sons first relapse occurred as a result of his AA sponsor convincing him that him utilizing his physician prescribed anti-depressant
as treatment, was the equivalent of him “not being sober”, and of
him, “not working the program”. He stopped taking his medication; he
suffered a binge episode that could have been fatal. He had been convinced by
his AA sponsor that his sobriety/abstinence and chips earned had been for nothing.

This brand of misinformed ignorance by 12-Step subscribers/sponsors -in influencing/advising members not to take their doctor
prescribed anti-depressants/antipsychotics, etc., -has long been a
problem in the program. This influence by 12-step peers/sponsors ranges
from occurring in a directly manipulative way, to a subtly manipulative
way. But, either way, this behavior is unconscionably irresponsible. But,
the aim/the goal should be to stop this kind of influence. And, the positive news is… it’s doable.

Examples of 12-Step peers and sponsors guilt-tripping, excluding, shaming AA
participants can be found very readily. Got a computer? Google it. The reality
is, is that this anti-social behavior does occur in ‘some’ AA groups -enough of
them that it is ‘common knowledge’ in the advocacy community. This negative
influence can be the result of one or more ‘bad eggs’ influencing the group dynamic:
‘Group Think’ gone wrong. And, in its worse version, this influence on members proves deadly, for some. All one need do to acknowledge this long known problem is ‘genuinely’ listen to those who have experienced this ‘unique-to-12 step’ byproduct…and research the phenomena ‘objectively’. There is plentiful evidence of this unhealthy ‘group think’ dynamic associated with AA/12 Step groups.

Does it mean ‘all’ the 12 step-based groups/all individual participants are infected with this potential of psychological sabotage of its peers in the program? Of course, not. But, reason and logic, as well
as the required application of empathy and compassion dictate that we all need to be paying attention to these reported experiences/incidences by those who have endured it. As advocates, we have an obligation to ensure that it stops.
Be VOCAL in your groups. Challenge the use of/the echoing of ‘old clichés’ such
as, “If his/her lips are moving they are lying”…(and many
other stereo-typing, anxiety/suspicion-increasing sayings veiled as
so-called ‘support’). These sayings need to be retired, as they are
examples of stigma-dragging, stereotyping, and marginalizing attitudes about
those individuals who are challenged by substances use disorder/co-occurring
disorder. And, the truth is, sometimes it’s the very people who are
so passionately involved in these groups that are inadvertently,
unintentionally causing a perpetuation of the stigma associated with the
condition of addiction. And this results in barriers to treatment and recovery
for patients and their families.

Stop referring to self and others as ‘drunks’, ‘junkies’,
etc. Use ‘person first’ terms when identifying others or yourself as
having a substances use/co-occurring disorder. At least, limit use of the

term ‘addict’ and ‘alcoholic’ as a description, whenever you can

Utilize more respecting, ‘individually’ supportive terms like, ‘Theresa’ is a person challenged by an addiction/substance(s) use disorder, etc. We think and speak stigma into being without even recognizing our role in it. Be respecting of the person, the condition/the challenge of addiction. Recognize the person, rather
than their addiction, as the ‘who’ that they are.

‘Call bs on bs when you see it/hear it in your meetings and elsewhere. Be brave ‘agents of change’ where change is needed. Evolution and change is inevitable. ‘Change’…building on the 12
Step program -especially where science has provided clinically-evidenced clarity in the biopsychosocial pathology associated
with addictions. This is, precisely, how we advocate and determine best
practices approach for ‘all’.

I witness it on a consistent basis: ‘gas
lightening’ in response to earnest people sharing about their negative
experience with 12 Step. If this gas lighting were not so disturbing and did not have such well being sabotaging risk associated; I would find it almost ‘amusing’ from a human behavior slant.

This gas lighting of former AA participants/12 step followers is common. And, that’s just unconscionable behavior. It doesn’t speak well of the program. And that’s sad. Because the 12 Step Philosophy has helped some find their way to increases in well being.

There are multiple paths to recovery. And, there are positives to be utilized in the 12 step model, as a support resource. !2-step is not considered ‘treatment’ in a clinical sense, but it works as very effective support for some. Let’s all ensure that ‘some’ influential, misinformed 12 Step subscribers don’t ruin it for those that would otherwise find help in its frame.

To add to the info in the above comment regarding success rates associated with different models of approach -Here is is evidence on
MI:

At 6 months after treatment, compared with the BA group, the MI group had
higher TSG affiliation [0.91 point higher AAAS score; 95% confidence interval
(CI) = 0.04 to 1.78; P = 0.041]. The MI group reported 3.5 fewer days of
alcohol use (2.1 versus 5.6 days; 95% CI = −6.5 to −0.6; P = 0.020) and 4.0
fewer days of drug use (3.8 versus 7.8 days; 95% CI = −7.5 to −0.4; P = 0.028);
however, abstinence rates and severity scores did not differ between conditions.
Analyses controlling for duration of in-patient treatment did not alter the
results.

Conclusions:

A motivational intervention in an in-patient detox ward was more successful
than brief advice in terms of patient engagement in 12-Step groups and reduced
substance use at 6 months after discharge. There is a potential benefit of
adding a maintenance-focused element to standard detox.

It is very nice collection in addiction recovery treatment. It is very helpful for me as well as others. So thanks for posting this blog.

hazlnut

More straw men than you can shake a stick at. I must be really lucky, because in the last 20 years I’ve only run into a small handful (minority) of AA meetings that are semi-cultish, and even with those were not ‘religious’.